Effects of the Fourth Ventricle Compression Technique and Rib Raising Osteopathic Technique on Autonomic Nervous System Activity Measured by Heart Rate Variability in 35 Healthy Individuals.

BACKGROUND Fourth ventricle compression (CV4) is a cranial osteopathic manipulation technique for brain and cranial nerve function. Rib raising is an osteopathic technique that reduces rib restriction and conditions associated with sympathetic hypertonia. This study aimed to evaluate the effects of the CV4 and rib raising osteopathic techniques on autonomic nervous system activity, measured by heart rate variability, in 35 healthy individuals. MATERIAL AND METHODS The study involved 35 healthy participants, randomly divided into 2 groups. The experimental group received osteopathic therapy in the form CV4 and rib raising techniques for 30 min. The placebo group had a sham procedure performed using an ultrasound transducer for 20 min. The test of heart rate variability was conducted for 6 min, with participants in a seated position. RESULTS A significant decrease in heart rate values was observed in the experimental group (P=0.012), and an increase in the standard deviation of all the rib raising intervals parameter and a decrease in the high frequency% parameter was observed in the placebo group (P=0.035, P=0.048; respectively). There were no differences in other parameters between the groups. CONCLUSIONS The use of the CV4 technique and rib raising technique leads to a significant decrease in heart rate, which can be interpreted as increased parasympathetic activity; however, the use of these techniques did not affect the other parameters.

Connecting the dots: alterations in bioelectric activity at acupuncture Ting (Jing-Well) points following CV4 cranial manipulation.

CONTEXT: The mechanisms by which osteopathic cranial manipulative medicine (OCMM) promotes health and healing have yet to be fully elucidated. One commonly utilized OCMM technique, compression of the fourth ventricle (CV4), has been theorized to balance autonomic nervous system (ANS) activity. There is growing evidence that the ANS also plays a significant mechanistic role in acupuncture. Potential connections between OCMM and acupuncture meridian theory largely remain unknown. OBJECTIVES: By measuring specific electrical parameters at acupuncture points that have been shown to correlate with ANS activity, the objectives of this study were to: 1) determine if CV4 has any influence on the bioelectric properties of the acupuncture meridian system; and 2) determine if CV4 affects the ANS. METHODS: A total of 77 males and females ages 18-78 years, all volunteers recruited by local flyers and personal or phone contact, were randomized into CV4 (n=40) and Sham (n=37) groups. All CV4 participants were treated by the same physician utilizing standard CV4 protocol. The Sham treatment, performed by a different physician, consisted of the supine participant's occiput resting passively on the physician's finger pads for a similar duration as those in the CV4 group. Among several devices developed to assess ANS activity at acupuncture points, evidence suggests that the Apparatus for Meridian Identification (AMI) is the most accurate and valid. Utilizing the AMI, bioelectric skin parameters were measured immediately before and after CV4 or Sham treatments. Student's or Welch's t tests and Wilcoxon tests were utilized for analysis of normally and non-normally distributed data, respectively. RESULTS: Statistical significance was determined with a p value less than 0.05. Sham treatments showed insignificant (p=0.754) before vs. after differences in ANS activity measured at acupuncture points, whereas CV4 treatment significantly (p=0.00015) affected ANS activity. CONCLUSIONS: This research suggests that CV4 has demonstrable biophysical effects on the acupuncture meridian system occurring via the ANS, and that the underlying mechanisms of OCMM and acupuncture may be related. Further studies are needed to clarify this.

Cranial osteopathic techniques and electroencephalogram (EEG) alpha power: a controlled crossover trial.

CONTEXT: Osteopathic tradition in the cranial field (OCF) stated that the primary respiratory mechanism (PRM) relies on the anatomical links between the occiput and sacrum. Few studies investigated this relationship with inconsistent results. No studies investigated the occiput-sacrum connection from a neurophysiological perspective. OBJECTIVES: This study aims to determine whether the sacral technique (ST), compared to the compression of the fourth ventricle (CV4) technique, can affect brain alpha-band power (AABP) as an indicator of a neurophysiological connection between the occiput and sacrum. METHODS: Healthy students, 22-30 years old for men and 20-30 years old for women, were enrolled in the study and randomized into eight interventions groups. Each group received a combination of active techniques (CV4 or ST) and the corresponding sham techniques (sham compression of the fourth ventricle [sCV4] or sham sacral technique [sST] ), organized in two experimental sessions divided by a 4 h washout period. AABP was continuously recorded by electroencephalogram (EEG) of the occipital area in the first 10 min of resting state, during each intervention (active technique time) and after 10 min (post-active technique time), for a total of approximately 50 min per session. Analysis was carried out utilizing a repeated-measure ANOVA within the linear general model framework, consisting of a within-subject factor of time and a within-subject factor of treatment (CV4/ST). RESULTS: Forty healthy volunteers (mean age ± SD, 23.73±1.43 years; range, 21-26 years; 16 male and 24 female) were enrolled in the study and completed the study protocol. ANOVA revealed a time × treatment interaction effect statistically significant (F=791.4; p<0.001). A particularly high increase in mean AABP magnitude was recorded during the 10 min post-CV4, compared to both the CV4 and post-sCV4 application (p<0.001). During all the times analyzed for ST and sST application, no statistically significant differences were registered with respect to the resting state. CONCLUSIONS: The ST does not produce immediate changes on occipital AABP brain activity. CV4, as previous evidence supported, generates immediate effects, suggesting that a different biological basis for OCF therapy's connection between the head and sacrum should be explored.

Variations of HRV and skin conductance reveal the influence of CV4 and Rib Raising techniques on autonomic balance: A randomized controlled clinical trial.

INTRODUCTION: The aim of the present study was to evaluate whether Fourth Ventricle Compression Technique (CV4) and Rib Raising (RR) osteopathic techniques influence Autonomic Nervous System (ANS) activity, as measured by Heart Rate Variability (HRV) and Skin Conductance (SC). METHOD: A randomized-controlled clinical trial has been performed from June 2010 to January 2011. 32 healthy adults (33.9 ± 14 years, and 72% female) were selected. Subjects were randomized in three groups: CV4 group, RR group and Placebo group. Each subject of each group underwent respective technique only once. HRV and SC were continuously recorded during the session. All data analysis was performed using SPSS statistical software (version 21.0) and the significance level was considered at p ≤ 0.05. RESULTS: RR technique intra-group subject analysis showed a significant decrease in LF/HF ratio (F = 25.18; p < 0.001), a statistically significant decrease of LF (F = 27.09; p < 0.001), and increase of HF, both at the end of treatment (F = 27.09; p < 0.001). CV4 technique intra-group subject analysis showed a significant reduction of the LF/HF ratio (F = 81.15; p < 0.001), a significant decrease in LF (F = 38.29; p < 0.001) and a significant increase of HF, at the end of treatment (F = 38.28; p < 0.001). Between-group analysis showed only a significant difference in LF/HF ratio between CV4 and PL groups (F = 3.44; p = 0.042). DISCUSSION: Our results suggest that the application of CV4 and RR techniques favors a shift in the autonomic balance towards a parasympathetic predominant state. Thus, their use within OMT protocol, as holistic approach, might improve the outcome of the treatment of clinical neuro-vegetative conditions.

Cerebral tissue oxygenation during cranial osteopathic CV4 procedure in newborns.

BACKGROUND: The cranial osteopathic manipulative medicine has been shown to alter regional cerebral tissue oxygenation (cStO2) in adult patients; however, there are no reports regarding the neonatal population. OBJECTIVES: To assess the influence of compression of the 4th ventricle (CV4) osteopathic procedure on cStO2 in neonates. MATERIAL AND METHODS: Thirty-one patients born between 25 and 39 weeks of gestation were screened for inclusion in the neonatal unit. Twenty-two infants presenting with hyperstimulation of autonomous nervous system (ANS) according to the Neonatal Behavioral Assessment Scale were enrolled in the study. Near-infrared spectroscopy was used for continuous cStO2 monitoring; pulse oximeter oxygen saturation (SpO2) and heart rate (HR) measured with pulse oximetry were simultaneously monitored 10 min before CV4, during the therapy and 10 min after it was stopped. RESULTS: Patients' condition remained stable throughout the study. There were no significant differences in the mean cStO2 values recorded before (69 ±8%), during (69 ±8%) and after CV4 (70 ±8%; p > 0.05). Mean SpO2 was almost constant during the study (96 ±4% before, 95 ±3% during and 95 ±4% after the intervention). Heart rate was also stable pre-, during and post-therapy (153 ±21 min, 151 ±18 min and 151 ±20/min, respectively). CONCLUSIONS: Compression of the 4th ventricle osteopathic procedure does not influence the cStO2 in newborns. This method seems to be well-tolerated but its clinical efficacy needs to be further investigated in this group of patients.

Does Compression of the Fourth Ventricle Cause Preterm Labor? Analysis of Data From the PROMOTE Study.

BACKGROUND: The technique for the compression of the fourth ventricle (CV4) in the brain has been described as a method of reaching the physiologic centers that reside in its floor and of restoring optimal flow of the cerebrospinal fluid. However, a study published as an abstract in 1992 questioned whether CV4, when applied to pregnant women, could induce uterine contractions and possibly labor. OBJECTIVE: To further examine whether CV4 could induce uterine contractions and labor as part of the osteopathic manipulative treatment (OMT) protocol used in the Pregnancy Research in Osteopathic Manipulation Optimizing Treatment Effects (PROMOTE) study. METHODS: Labor and delivery data collected during the PROMOTE study from 2007-2011 were analyzed. The PROMOTE study was funded by the National Institutes of Health and was a randomized controlled clinical trial that measured the primary outcomes of back-specific functioning and pain in pregnant women aged 18 to 34 years. Participants were randomly divided into 3 groups-usual obstetric care only, placebo ultrasound treatment plus usual obstetric care, and OMT plus usual obstetric care. Study participants were scheduled for 7 treatment visits. Presented data were gathered from labor and delivery records. RESULTS: Four hundred participants were included. No significant differences were identified between treatment groups for the development of high-risk status (P=.293) or preterm delivery (P=.673). Evaluation of high-risk status by preterm delivery for the groups also showed no significant differences between groups (P=.455). CONCLUSION: The application of CV4 as part of an OMT protocol during the third trimester caused neither a higher incidence of preterm labor nor the development of high-risk status.

Low-dose infusions of leptin into the nucleus of the solitary tract increase sensitivity to third ventricle leptin.

Previous studies suggest that weight loss occurs when leptin receptors in both the forebrain and hindbrain are activated. Experiments described here tested whether this integration is mediated through a neural connection or by leptin diffusion through the subarachanoid space. If the hypothalamus and hindbrain communicated through a neural pathway, then a very low dose of leptin infused directly into the nucleus of the solitary tract (NTS) would enhance the response to third ventricle (3V) leptin but would have no effect if infused into the fourth ventricle (4V). A 12-day infusion of 10 ng/24 h into the 4V or the NTS reduced body fat. Leptin at 5 ng/24 h into the 4V or NTS had no effect on food intake or body composition, but infusion of 5 ng of leptin/24 h into the NTS combined with a 3V injection of 0.1 µg of leptin inhibited food intake between 6 and 12 h after injection. Cumulative intake was inhibited for up to 36 h. 3V leptin had no effect on food intake of rats receiving the 4V leptin infusion. Similar results were found using infusions of 5 ng leptin/24 h and a 3V injection of 0.025 µg leptin. These data suggest that activation of leptin receptors in the NTS lowers the threshold for response to leptin in the forebrain through a neural network.

Cardiac autonomic response after cranial technique of the fourth ventricle (cv4) compression in systemic hypertensive subjects.

OBJECTIVE: The aim of this study was to compare blood pressure (BP) behavior and heart rate variability (HRV) among hypertensive stage I and normotensive individuals who were submitted to the cranial technique of the 4th ventricle compression (CV4), an osteopathic technique. METHODS: In this experimental controlled study, thirty men between 40 and 60 years old were evaluated and divided into two groups: normotensive (NT) and hypertensive (HT). The CV4 maneuver was applied in both groups and BP was measured at 5 (five) different stages: pre and post-intervention, 5, 10 and 15min after technique. Time-frequency parameters were obtained from measurements of RR intervals. Data were analyzed using an ANOVA two-way for analysis of the condition factor (NT and HT) and times with p-value ≤ .05. RESULTS: There was a reduction in the BP of the HT group. A significant intergroup difference (p = .01) was noticed, with respect to the standard deviation of successive normal R-R intervals (SDNN) values, mainly between pre-intervention and 15min stages. Concerning root mean square of the mean squared differences (RNSSD) values, the highlights were differences between pre-intervention and 10min (p = .01) only in the NT group. There was an increase in high frequencies (HF) values and a low frequencies (LF) attenuation in both groups at all different stages. CONCLUSION: The data showed a BP reduction in the HT group in pre-intervention/15min and an increase in parasympathetic activity and decreased sympathetic activity in both groups. This suggests a change in the sympathetic-vagal balance. However, further studies are needed to elucidate the data on BP reduction mechanisms with CV4.

A novel neuromodulation technique for the rehabilitation of balance and gait: A case study.

Cranial-nerve non-invasive neuromodulation (CN-NINM) through the tongue has been proposed as an adjuvant intervention to improve efficacy of rehabilitation. However, CN-NINM effects have only been explored in multiple sclerosis and stroke populations. In this report we used CN-NINM during a 2-week (2 × 1.5 h sessions daily) physiotherapy program for the rehabilitation of a 57 y/o woman presenting with balance and gait impairments after a surgical resection of a fourth ventricular ependymoma. Clinical and instrumented balance and gait assessments showed improved performance in all tests and without adverse effects This study shows the beneficial effects and feasibility of combined physiotherapy and CN-NINM in this patient.

The superior fovea triangle approach: a novel safe entry zone to the brainstem.

The authors describe a safe entry zone, the superior fovea triangle, on the floor of the fourth ventricle for resection of deep dorsal pontine lesions at the level of the facial colliculus. Clinical data from a patient undergoing a suboccipital telovelar transsuperior fovea triangle approach to a deep pontine cavernous malformation were reviewed and supplemented with 6 formalin-fixed adult human brainstem and 2 silicone-injected adult human cadaveric heads using the fiber dissection technique to illustrate the utility of this novel safe entry zone. The superior fovea has a triangular shape that is an important landmark for the motor nucleus of the trigeminal, abducens, and facial nerves. The inferior half of the superior fovea triangle may be incised to remove deep dorsal pontine lesions through the floor of the fourth ventricle. The superior fovea triangle may be used as a safe entry zone for dorsally located lesions at the level of the facial colliculus.

Fourth-ventricle leptin infusions dose-dependently activate hypothalamic signal transducer and activator of transcription 3.

Previous studies have shown that very low-dose infusions of leptin into the third or the fourth ventricle alone have little effect on energy balance, but simultaneous low-dose infusions cause rapid weight loss and increased phosphorylation of STAT3 (p-STAT3) in hypothalamic sites that express leptin receptors. Other studies show that injecting high doses of leptin into the fourth ventricle inhibits food intake and weight gain. Therefore, we tested whether fourth-ventricle leptin infusions that cause weight loss are associated with increased leptin signaling in the hypothalamus. In a dose response study 14-day infusions of increasing doses of leptin showed significant hypophagia, weight loss, and increased hypothalamic p-STAT3 in rats receiving at least 0.9 µg leptin/day. In a second study 0.6 µg leptin/day transiently inhibited food intake and reduced carcass fat, but had no significant effect on energy expenditure. In a final study, we identified the localization of STAT3 activation in the hypothalamus of rats receiving 0, 0.3, or 1.2 µg leptin/day. The high dose of leptin, which caused weight loss in the first experiment, increased p-STAT3 in the ventromedial, dorsomedial, and arcuate nuclei of the hypothalamus. The low dose that increased brown fat UCP1 but did not affect body composition in the first experiment had little effect on hypothalamic p-STAT3. We propose that hindbrain leptin increases the precision of control of energy balance by lowering the threshold for leptin signaling in the forebrain. Further studies are needed to directly test this hypothesis.

Thalamic rosette-forming a glioneuronal tumor in an elderly patient: Case report and literature review.

The rosette-forming glioneuronal tumor (RGNT) is a novel type of brain tumor recently listed in the WHO 2007 classification of central nervous system (CNS) tumors. We report the case of a 75-year-old woman harboring a thalamic RGNT with third ventricle dissemination. Age and location make the present case exceptional and which has never previously been reported. A review of the clinical, pathological and radiological features is presented along with the relevant literature.

Fourth ventricular CART peptide induces c-fos in the area postrema and nucleus of the solitary tract via a CRF-receptor dependent mechanism.

Cocaine-and amphetamine-regulated transcript peptides (CARTp) suppress gastric emptying and nutritional intake following 4th icv administration. Whereas, the CARTp inhibition of gastric emptying was blocked by pre-treatment with a non-selective corticotropin releasing factor (CRF) antagonist, sucrose drinking was not, suggesting that CARTp- and CRF controls for food intake and gastric emptying are operated through separable dorsal hindbrain mechanisms. The aim of the study was to explore CARTp-CRF brainstem interactions on patterns of neuronal activation in areas of the brainstem and midbrain relevant to gastrointestinal control and feeding regulation. Rats received 4th icv injections of combinations of vehicle, CARTp (1µg), or the nonselective CRF antagonist, α-helical CRF9-41 (αCRF), in a randomized order. Brain sections were processed for c-fos by immunohistochemistry followed by image analysis at defined levels of the brain. CARTp (1µg, 4th icv) induced a robust c-fos response in the nucleus of the solitary tract (NTS) and area postrema (AP), whereas, no c-fos could be detected in the parabrachial nucleus (PBN), the paraventricular nucleus of the hypothalamus (PVN) or the arcuate nucleus of the hypothalamus (ARC). The c-fos expression in the structures of the dorsal vagal complex (DVC) was completely blocked by pre-treatment with the CRF antagonist, which did not by itself induce c-fos at any examined level. After CARTp and αCRF in combination, there was a tendency towards an increased c-fos response in the ARC. We conclude that CARTp activates cells of the area postrema and NTS via a downstream, CRF-dependent mechanism.

Unusual primary central nervous system lymphoma location involving the fourth ventricle and hypothalamus.

A previously healthy 65-year-old man presented with a two-week history of weight loss, headaches, blurred vision, asthenia and quickly worsening walking impairment. He denied photophobia, neck stiffness, fever, nausea or vomiting.Neurological examination showed global motor slowing, tendency to fall asleep during the clinical examination, generalized weakness against resistance to head and limbs, and osteotendon reflexes present in the upper limbs, but not evoked in the lower limbs. No sensitive deficit or focal neurologic sign was recognizable.Non-contrast multislice computed tomography (MSCT) of the head was performed in the emergency department, showing diffuse periventricular white matter and thalamic mild hyperdensity.Lumbar puncture, blood tests, including serology for HIV and other infections, were negative.On the third day the patient, showing decreased consciousness, underwent magnetic resonance imaging (MRI) with contrast medium injection. MRI revealed the presence of multiple pseudonodular avidly enhancing lesions, supra and infratentorial, crossing the midline, involving the ventricular system, including the fourth ventricle, with extension into the surrounding white matter, the corpus callosum, the thalamus and the hypothamalus.A stereotactic biopsy led to a diagnosis of diffuse large B-cell lymphoma, primarily located in the central nervous system (PCNSL).After the completion of the first phase of treatment (immunotherapy with intravenous Rituximab and corticosteroid), the MRI showed a marked regression of tumor masses.

Microsurgery and radiosurgery for brainstem cavernomas: effective and complementary treatment options.

OBJECTIVE: To evaluate treatment options for brainstem cavernous malformations (BSCMs) using the results from a center with long-standing experience in microsurgical resection and Gamma Knife radiosurgery (GKRS) treatment of BSCMs. METHODS: Study participants were 67 symptomatic patients with BSCMs who were treated either microsurgically (n = 29) or radiosurgically (n = 38). Patients were followed for a minimum of 2 years (median, 7.7 years). A recent follow-up was performed. RESULTS: Patients receiving surgical treatment had mainly large, superficially seated lesions and experienced preoperative hemorrhages more often and presented with higher preoperative modified Rankin Scale scores. Patients receiving GKRS harbored smaller, deep-seated lesions, reflecting a selection bias. In both treatment groups, patients presented with significantly better modified Rankin Scale scores at follow-up than before intervention. Overall annual preoperative hemorrhage rates were 3.2% in microsurgery patients and 2.3% in radiosurgery patients. In the preoperative observation period, the rehemorrhage rate was 25.1% for microsurgery patients and 7.2% for radiosurgery patients. Hemorrhage rate after GKRS decreased significantly to 0.6% after 2 years. The postoperative hemorrhage rate was 8.8% but only for microsurgery patients with residual lesions. Advancements in microsurgical techniques improved surgical outcomes, resulting in a high total excision rate in the modern era. CONCLUSIONS: In the treatment of BSCM, patient selection and timing of surgery are crucial. If applied in a multidisciplinary neurosurgical center, microsurgery and radiosurgery are complementary treatment options that both result in reduced bleeding rates and improvement of clinical outcome.

Blockade of the cerebral aqueduct in rats provides evidence of antagonistic leptin responses in the forebrain and hindbrain.

Previously, we reported that low-dose leptin infusions into the fourth ventricle produced a small but significant increase in body fat. These data contrast with reports that injections of higher doses of leptin into the fourth ventricle inhibit food intake and weight gain. In this study, we tested whether exogenous leptin in the fourth ventricle opposed or contributed to weight loss caused by third ventricle leptin infusion by blocking diffusion of CSF from the third to the fourth ventricle. Male Sprague-Dawley rats received third ventricle infusions of PBS or 0.3 µg leptin/24 h from miniosmotic pumps. After 4 days, rats received a 3-µl cerebral aqueduct injection of saline or of thermogelling nanoparticles (hydrogel) that solidified at body temperature. Third ventricle leptin infusion inhibited food intake and caused weight loss. Blocking the aqueduct exaggerated the effect of leptin on food intake and weight loss but had no effect on the weight of PBS-infused rats. Leptin reduced both body fat and lean body mass but did not change energy expenditure. Blocking the aqueduct decreased expenditure of rats infused with PBS or leptin. Infusion of leptin into the third ventricle increased phosphorylated STAT3 in the VMHDM of the hypothalamus and the medial NTS in the hindbrain. Blocking the aqueduct did not change hypothalamic p-STAT3 but decreased p-STAT3 in the medial NTS. These results support previous observations that low-level activation of hindbrain leptin receptors has the potential to blunt the catabolic effects of leptin in the third ventricle.

Caudal fourth ventricular administration of the AMPK activator 5-aminoimidazole-4-carboxamide-riboside regulates glucose and counterregulatory hormone profiles, dorsal vagal complex metabolosensory neuron function, and hypothalamic Fos expression.

This study investigated the hypothesis that estrogen controls hindbrain AMP-activated protein kinase (AMPK) activity and regulation of blood glucose, counterregulatory hormone secretion, and hypothalamic nerve cell transcriptional status. Dorsal vagal complex A2 noradrenergic neurons were laser microdissected from estradiol benzoate (E)- or oil (O)-implanted ovariectomized female rats after caudal fourth ventricular (CV4) delivery of the AMPK activator 5-aminoimidazole-4-carboxamide-riboside (AICAR), for Western blot analysis. E advanced AICAR-induced increases in A2 phospho-AMPK (pAMPK) expression and in blood glucose levels and was required for augmentation of Fos, estrogen receptor-α (ERα), monocarboxylate transporter-2, and glucose transporter-3 protein in A2 neurons and enhancement of corticosterone secretion by this treatment paradigm. CV4 AICAR also resulted in site-specific modifications in Fos immunolabeling of hypothalamic metabolic structures, including the paraventricular, ventromedial, and arcuate nuclei. The current studies demonstrate that estrogen regulates AMPK activation in caudal hindbrain A2 noradrenergic neurons during pharmacological replication of energy shortage in this area of the brain, and that this sensor is involved in neural regulation of glucostasis, in part, through control of corticosterone secretion. The data provide unique evidence that A2 neurons express both ERα and -ß proteins and that AMPK upregulates cellular sensitivity to ERα-mediated signaling during simulated energy insufficiency. The results also imply that estrogen promotes glucose and lactate uptake by these cells under those conditions. Evidence for correlation between hindbrain AMPK and hypothalamic nerve cell genomic activation provides novel proof for functional connectivity between this hindbrain sensor and higher order metabolic brain loci while demonstrating a modulatory role for estrogen in this interaction.

Changes in alpha band activity associated with application of the compression of fourth ventricular (CV-4) osteopathic procedure: a qEEG pilot study.

The compression of the fourth ventricle (CV-4) is one of the more well known procedures in the cranial manipulation curriculum and practice. Cranial manipulation has received criticism because of the subtle, difficult to learn techniques, controversy over whether or not cranial bone structures move, and what if any clinical effects have been shown. The aim of this study was to measure the effects of CV-4 in 10 healthy subjects through quantitative electroencephalography (qEEG), specifically in alpha band. Participants were randomly distributed in control, sham-CV4 and CV4 conditions using a cross-over design. qEEG activity was recorded for each of the 10 subjects in each of the 3 conditions. There was a significant increase in the alpha absolute power between pre and post in the CV-4 condition. There appears to be potential for understanding the effect of the CV-4 if these finding are replicated in further clinical trials.

Microscopic supraciliary approach for terminal laminotomy for treatment of hydrocephalus: a preliminary report of eight cases.

AIM: Shunting and endoscopic third ventriculostomy for treatment of hydrocephalus have their own complications which make the management of such patients more difficult. We have examined the subfrontal route to fenestrate lamina terminalis in order to achieve relief of hydrocephalus in eight consecutive patients. MATERIAL AND METHODS: Eight patients with the diagnosis of hydrocephalus were chosen. A supraciliary approach to the central skull base was used to fenestrate the lamina terminalis to allow cerebrospinal fluid egress from the third ventricle to the basal cisterns. RESULTS: Clinical and/or radiological remission of hydrocephalus symptoms were observed in all patients. No complications were encountered in this small series of patients. CONCLUSION: Microsurgical third ventriculo-cisternostomy through a supraciliary might be a reasonable alternative to endoscopic third ventriculostomy. However, a more sample size with controlled subjects is required to draw conclusions and comparisons with other techniques of treatment of hydrocephalus.

Treatment of Hydrocephalus Associated with Neurosarcoidosis by Multiple Shunt Placement

A 31-year-old man was admitted to our hospital due to hydrocephalus with neurosarcoidosis. Ventriculo-peritoneal shunting was performed in the right lateral ventricle with intravenous methylprednisolone. Subsequently, after 4 months, additional ventriculo-peritoneal shunting in the left lateral ventricle was performed due to the enlarged left lateral ventricle and slit-like right lateral ventricle. After 6 months, he was re-admitted due to upward gaze palsy, and magnetic resonance image showed an isolated fourth ventricle with both the inlet and outlet of fourth ventricle obstructed by recurrent neurosarcoidosis. Owing to the difficulty of using an endoscope, we performed neuronavigator-guided ventriculo-peritoneal shunting via the left lateral transcerebellar approach for the treatment of the isolated fourth ventricle with intravenous methyl prednisolone. The patient was discharged with improved neurological status.